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2 Safe Kids Canada 180 Dundas Street West, Suite 2105 Toronto ON M5G 1Z8 Office phone number: Information line: SAFE-TIP ( ) Safe Kids Canada s mission is to lead and inspire a culture of safety across the country in order to reduce unintentional injuries, the leading cause of death among children and youth in Canada. As a national leader, Safe Kids Canada uses a collaborative and innovative approach to develop partnerships, conduct research, raise awareness and advocate in order to prevent serious injuries among children, youth and their families. Our vision is Fewer Injuries. Healthier Children. A Safer Canada. Safe Kids Canada is the national injury prevention program of The Hospital for Sick Children. Production of these materials have been made possible through a financial contribution from the Public Health Agency of Canada. The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada Text or parts of the text may be copied, provided that reference is made to the authors, title of the publication and publisher. Suggested citation: MacKay M, Vincenten J, Brussoni M, Towner E, Fuselli, P. Child Safety Good Practice Guide: Good investments in unintentional child injury prevention and safety promotion - Canadian Edition. Toronto: The Hospital for Sick Children, ISBN April 2011

3 TABLE of CONTENTS Introduction...2 Contents of the Guide...3 Section 1: What do we know about good practice approaches to preventing unintentional injuries in children?...4 Why should we focus on evidence-based good practice?...6 Why do we not implement good practice?...6 Section 2: Good practice at-a-glance...8 Good practice for child passenger safety...9 Good practice for child pedestrian safety...10 Good practice for child cyclist safety...11 Good practice for child water safety...12 Good practice for fall prevention in children...14 Good practice for burn & scald prevention in children...15 Good practice for poisoning prevention in children...17 Good practice for choking /strangulation prevention in children...18 Good practice for general child home safety...19 Good practice for general community-based child injury prevention...20 Good practice for system leadership, infrastructure and capacity to support child injury prevention...21 Section 3: When and how should we use good practice in planning injury prevention strategies?...22 What issues should be considered when selecting strategies?...24 What else can be done to support a culture of good practice in child injury prevention and safety promotion?...27 Section 4: Methodology for case studies...32 Section 5: Good Practice Case Studies from Canada...34 Child Passenger Safety Promotion in Aboriginal Communities (Manitoba)...36 Pace Car Program (Nova Scotia)...38 Operation Headway (Nova Scotia and Prince Edward Island)...40 Personal Floatation Device Program (Manitoba)...42 Pool Fencing Bylaw (Ontario)...44 Swim to Survive (Ontario)...46 Safer Play Equipment on Playgrounds (Ontario)...48 A Million Messages (Alberta)...50 Safety Kit Program (Quebec)...52 TD ThinkFirst for Kids Curriculum (National)...54 Acquired Brain Injury Strategy (Saskatchewan)...56 Atlantic Collaborative on Injury Prevention (New Brunswick, Newfoundland and Labrador, Nova Scotia and Prince Edward Island)...58 Canadian Hospital Injury Reporting and Prevention Program (National)...60 Canadian Surveillance System for Water Related Fatalities (National)...62 Economic Burden of Injury in Canada reports (National)...64 Provincial Injury Prevention Strategy (Nova Scotia)...66 Safe Kids Week 2001: Prevention of Scald and Burn Injuries in Young Children (National)...68 Acknowledgements...70 References

4 INTRODUCTION The need for knowledge of what works is growing every day among those working to reduce the burden of unintentional injuries amongst Canada s children. Injury is the number one cause of death for children in Canada, accounting for 30% of all deaths and the largest environmental burden of disease, with an average of 300 deaths for children less than 14 years of age, every year.(1,2) That is to say 25 children die from injury every month, the equivalent of one classroom of children per month. Injury prevention efforts in Europe that were supported by the European Union resulted in the publication of the original Child Safety Good Practice Guide: Good investments in unintentional child injury prevention and safety promotion (the European Guide). The European Guide was launched by the European Child Safety Alliance (the Alliance) to provide guidance on proven, effective injury prevention strategies. The need for Member States to develop national action plans to prevent injury increased the demand to deliver effective interventions at the national and local levels.(3-5) Good use of evidence is central to achieving this and knowing what works is at the heart of developing good policy and programs. Safe Kids Canada has formally partnered with the Alliance to bring a Child Safety Good Practice Guide to Canada. Safe Kids Canada is the national injury prevention program of The Hospital for Sick Children. Safe Kids Canada s mission is to lead and inspire a culture of safety across Canada in order to reduce unintentional injuries. Injuries to children could be significantly reduced if proven safety strategies were adopted and implemented across all provinces and territories in Canada. The Canadian Edition of the Child Safety Good Practice Guide provides the first seminal comprehensive document in the country from which decision-makers, practitioners and legislators can base their work and recommendations. It will enable Canadian injury prevention practitioners to examine Canadian strategy options for unintentional child injury, move away from what has always been done and move toward good investments - strategies that are known to work or have the greatest probability of success. Through the use of this Canadian Edition, efforts can be focused on those interventions that are most effective and can result in the reduction of injuries leading to hospitalization or death. The value of good practice is realized when the best available research evidence is combined with the practical expertise of professionals in the real world. This approach requires that professionals are aware of both best evidence and practical aspects of transferring policies and programs from one setting to another. With so much to do to address the safety of Canadian children and so little time and limited resources, there is a need to focus on good investments, those strategies that are most likely to reduce childhood unintentional injuries. For the purpose of this document good practice is defined as: A prevention strategy that has been evaluated and found to be effective (either through a systematic review or at least one rigorous evaluation) OR A prevention strategy where rigorous evaluation is difficult but expert opinion supports the practice and data suggest it is an effective strategy (e.g., use of personal floatation devices (PFD) to prevent drowning) OR A prevention strategy where rigorous evaluation is difficult but expert opinion supports the practice and there is a clear link between the strategy and reduced risk but a less clear link between the strategy and reduced injuries (e.g., secure storage of poisonings) AND The strategy in question has been implemented in a real world setting so that the practicality of the intervention has also been examined. This Canadian Edition builds on previous work by child safety researchers from around the globe and is a further step in supporting Canada in moving toward evidence-based good practice. It is acknowledged that knowing what worked in one setting is not enough and the transfer and implementation points and Canadian case studies included in this Canadian Edition are included as information to guide decision-making and illustrations of good practice in action. It is hoped that this information will begin to provide initial thoughts on why a strategy worked and provide some guidance for transfer to new settings. However, more work is needed to understand all the factors that influence the success of a strategy that is transferred from one setting to another. Finally, the synthesis of existing knowledge compiled in the development of this resource also allows the identification of situations where there is a need to evaluate existing interventions and where good practice strategies do not exist. 2

5 CONTENTS of the GUIDE This guide is divided into four sections to help injury stakeholders promote good practice in planning and implementing strategies to address child injury. Note that the terms child injury prevention and child safety are used interchangeably. SECTION 1 Introduces the concept of good practice and discusses general approaches for policy and programs in the areas of child injury prevention and safety promotion. SECTION 2 Provides a series of at-a-glance tables that identify effective strategies (current good practice) in the following areas of child injury prevention and safety promotion: passenger safety pedestrian safety cyclist safety water safety fall prevention burn and scald prevention poisoning prevention choking/strangulation prevention general home safety (strategies not already covered in topics above) general community-based injury prevention (strategies not already covered in topics above) activities in the area of system leadership, infrastructure and capacity. For each area, a table provides: 1] a series of evidence statements describing current good practice; 2] an indication of whether a case study for that particular strategy has been identified and included and 3] suggestions for transferring and implementing the strategy. Each example of good practice is also colour coded to provide an indication of which of the 3 E s of injury prevention is the focus; > ENGINEERING (modification of a product/environment), > ENFORCEMENT (policy/legislation and measures to ensure compliance), or > EDUCATION (education/behaviour change strategies). The traditional approach to the three E s of injury prevention has often been described in somewhat simplistic and limiting terms.(6) We encourage you to consider the E s of prevention in their broadest context, recognizing that they are tools for helping us establish large scale changes in healthy public policy and the creation of environments, both social and physical, which allow the safe behaviour to be the easy behaviour. SECTION 3 Provides information about where in the planning cycle information on good practice can be applied and about selecting and transferring good practice from one setting to another. The importance of advocating for, building and maintaining, a culture of good practice is described and stressed. SECTION 4 Describes in detail the methods used for developing case studies. SECTION 5 Provides a series of case studies illustrating implementation of select at-a-glance strategies in the field of child injury prevention and safety promotion and lessons learned from application of strategies in Canada. 3

6 SECTION1 What do we know about good practice approaches to preventing unintentional injuries in children? Prior to examining the actual good practice approaches to preventing unintentional injuries in children, it is important to note that preventing injury in this age group is unique for a number of reasons. To plan and implement truly effective strategies, it is essential to take these factors into account when selecting and transferring good practice. The uniqueness stems from: Children as the focus of the work: When talking about child injury prevention and safety promotion, children and their parents/caregivers are the primary target groups of interventions. Although a specific intervention might involve advocating for policy change with decision-makers, the main focus for child injury prevention and safety promotion is the children themselves and the adults who are their main caregivers.(5,7-12) The importance of children s developmental stage: The types of injuries that children experience are closely linked with their age and stage of development which involves physical, psychological and behavioural characteristics.(13) This needs to be taken into account when examining potential strategies and transferring them to new settings. The fact that injuries disproportionately affect the most vulnerable children in society: The likelihood of a child being killed or injured is associated with a variety of factors including single parenthood, low education among mothers, very young mothers, poor housing and parental drug or alcohol abuse.(14) Further economic and social factors that can influence health and injury include income, employment, food security, age, gender and social inclusion, often referred to as the social determinants of health. In early 2009, the WHO released a policy briefing, Addressing the Socioeconomic Safety Divide.(15) The briefing concluded that people with low socioeconomic status and those who live in poor neighbourhoods are more likely to die as a result of injury and violence than people who live in wealthy neighbourhoods. This applies to many of the leading causes of injury globally, including motor vehicle crashes, poisoning and burns. The WHO briefing was based on a systematic review of the literature on injury, and points to the importance of understanding and acting on the broad socioeconomic conditions in which injury occurs. This uniqueness of children mandates the importance of knowing your target audience well and involving your target group early on in the project.(16, 17) Failing to involve your target group is likely to reduce the success of an intervention. Particularly when transferring a good practice from one setting to another, it is important to know your target group as rigorous evaluations, such as those used to support best evidence recommendations, typically have limited generalizability because of the specificity of their participants. 4

7 When broad approaches to child injury prevention and safety promotion are examined, there are seven that offer proven or promising strategies.(9) These seven approaches are described below but it is important to note that although they have been proposed as offering proven or promising strategies, actual strategies based on these approaches have not been evaluated in all areas of child injury prevention. Nonetheless, they provide a useful framework to consider for any type of childhood injury. 1) Environmental modification children are particularly vulnerable to injury because they live in a world over which they have little control and which is built around the needs of adults.(15) Modification of the environment to make that world more child- or parent- friendly is an accepted approach to reducing risk and can impact positively on everyone. These strategies are most effective when used in combination with legislation and educational activities.(9) Examples of this type of strategy in the at-a-glance section include playground equipment design and installation and area-wide measures to reduce pedestrian and cyclist risk (e.g., traffic calming). 2) Product modification similar to the issues in environmental modification, many products pose an added risk to children because they are designed around the needs of adults. Product modification is a more passive means than active adult supervision of reducing the risk around certain products.(18) These strategies also become more effective when used in conjunction with legislation and educational activities. Examples of this type of strategy in the at-a-glance section include factory set temperatures on water heaters and child resistant lighters. 3) Legislation, regulation and enforcement legislation has proven to be the most powerful tool in the prevention of injury.(9) Legislation is most effective when enforced and when used in combination with product or environmental modification and educational activities. Examples of this type of strategy in the at-a-glance section include legislation around the use of child passenger restraints, bicycle helmets and child resistant packaging. 4) Promoting the use of safety devices safety devices are promoted to reduce the risk of injury occurrence or minimize the impact in the event of an injury event.(9) Examples of this type of strategy in the at-a-glance section include smoke detectors, bicycle helmets and child passenger restraints. 5) Supportive home visits to families of young children although more evaluation is required of supportive home visits, early studies have found generally positive results for this approach. Supportive home visits are particularly effective if the information provided is age appropriate and visits are combined with provision of free safety equipment and broader promotional campaigns.(19) 6) Community-based interventions these interventions, which focus on changing community values and behaviours and altering the physical environment of communities to reduce the risk of injury, may have particular relevance for children as interventions often target the safety awareness, attitudes, and behaviours of children and parents.(20) Community-based interventions employ a broad array of strategies that include education/behaviour change, product and environmental modification and legislation/enforcement, with the key difference that the strategy focuses on the community, not the individual. Examples of this type of strategy in the at-a-glance section include community-based bicycle helmet and child passenger restraint promotional campaigns. 7) Education and skills development the effectiveness of educational and skill development programs on their own is controversial and evidence is often lacking. However if they are well designed and take into account the target population, or if they are used in combination with other strategies, such as legislation or environmental or product modification, educational and skills development programs can be effective.(9) An example of this type of strategy in the at-aglance section includes pedestrian skills training. These approaches include both active and passive interventions. Active interventions require action at the individual level for the intervention to be effective.(21) For example, a cyclist has to put on a helmet each time they ride a bike and a child has to be belted in a car seat each time they ride in a car. At the other end of the continuum, passive interventions provide automatic protection without requiring action from an individual (e.g., regulatory standards for playground equipment and legislation requiring child resistant packaging for pharmaceuticals).(21) Passive strategies are preferred over active strategies because they are automatic, protect everyone and require no action or cooperation from the individual. However, sometimes passive strategies cannot be used because there are insufficient resources, the proposed strategy is socially unacceptable and/or there is no passive strategy available. In practice, interventions developed are often a mix of passive and active. For example, comprehensive prevention of playground injuries requires passive interventions (installation of playground equipment that meets regulatory standards) and active interventions (maintenance of equipment/landing surfaces and adequate supervision by parents/caregivers). 5

8 SECTION 1 Why should we focus on evidence-based good practice? Transfer of knowledge can happen with both effective and ineffective practices and numerous ineffective strategies continue to be practiced across Canada despite evidence that they are not the best use of resources. For example, bicycle skills fairs or rodeos as an educational strategy to address bicycle-related injuries have not been shown to be effective and as a solitary strategy are not considered good practice.(18) When combined with helmet giveaways or the offer of subsidized helmets, this intervention has shown more positive outcomes (22) but despite this evidence, the activity continues to be offered as a stand-alone intervention. In the current environment of scarce resources and competing issues the injury prevention community needs to ensure that existing efforts and resources are focused on effective evidencebased good practice. It also needs to ensure that it systematically studies and understands why strategies work in one setting/context and not in others and it needs to learn to effectively transfer the good practice to other settings/contexts. If the injury prevention community does not make adopting evidence-based good practice a priority, policy makers will continue to invest resources in strategies that do not lead to reducing the burden of injury in children. Why do we not implement good practice? There are several reasons why, as a field, the injury prevention community fails to select and implement good practice: Resistance to change Resistance can come from government in the form of resistance to legislative or regulatory efforts, from the injury prevention community in terms of comfort with the way things are, personal investment in an existing unproven program or lack of awareness of a need to change. It can also come from the program developers and managers because producing an educational pamphlet as the sole intervention is easier, faster and more quantitative than advocating for legislation or environmental modifications or because funders may only be willing to provide funds for this purpose. The public itself can also play a role. If an activity is perceived by the public to be of value, even if it is actually not effective, then politicians and decision-makers often hesitate to stop investing. Understanding where resistance is likely to come from and planning accordingly to address it is part of good practice in transferring strategies from one setting to another. Competing priorities While the importance of keeping children alive and contributing to society seems inherently simple and essential, it also takes ongoing commitment. This usually requires more time, money or potential inconvenience for adults and as a result the ongoing commitment is not made. For example, sometimes what is safe for children is not perceived to be good for others (e.g., adults, industry, etc.). A product modification that is viewed as important to ensuring a reduced risk for child injury may be seen as being in conflict with what is best for industry. This is because industry tends to see the desired changes resulting in increased production costs, job losses, etc. This in turn can impact elected officials who attempt to balance perceived needs and may side with industry for fear of not being reelected and loss of corporate support. Selecting and following through with good practice requires real commitment for the long term and beyond a single election cycle. Because in injury prevention a given strategy can affect multiple sectors, ministries, industry and partners it is important to understand the many viewpoints and to build the strongest case for the child-benefiting change. It is therefore important that the injury prevention field continues to build the evidence of effective strategies, including costeffectiveness of strategies, so that data are available to support arguments for children s lives as the priority over other issues. Failure to plan solutions effectively If too little time is spent on up front planning then the steps of looking for good practice from other settings may be missed. Furthermore, once good practice is identified, failure to assess adequately the potential for successful transfer and to plan concrete steps to increase its likelihood can result in unsuccessful transfer and implementation. And unsuccessful transfer and implementation can have a negative impact on the field as a whole if it is interpreted as a failure of the strategy rather than a failure of the transfer and implementation. The amount of time, work and practical research required to obtain the necessary information and do a good job on these planning steps can be daunting. As the injury prevention field learns more about what works and why, resources such as this guide can help by identifying good practice and providing guidance for the decision to attempt transfer and steps to increase likelihood of success. 6

9 Lack of capacity or expertise In some cases the individuals making the decisions do not have the information necessary to make the correct decision and choose good practice. There is therefore a role for injury prevention practitioners to educate decision-makers and to advocate for commitment and resources for strategies that will work. There is a role for lead organizations in the injury prevention and safety promotion field to support the efforts of injury prevention practitioners to advocate for good practice and also to address capacity building as a priority issue in the field. In Canada in 2011, few people are employed with a mandate related only to injury prevention. We encourage you to consider yourself an injury prevention practitioner if you work or conduct research in the fields of health promotion, public health and safety, injury prevention, or if you facilitate activities that promote safety on a volunteer basis in your community. Moreover, we recognize that good practice requires us to integrate our efforts among those working to create healthier and safer communities. If you work in the field of healthy living, substance abuse prevention, mental health, policing or social services to name a few, you do already make a meaningful contribution to the prevention of injuries. You are indeed, an injury prevention practitioner. Lack of time or resources Often practices that are not evidence-based can be appealing because they are quick and easy and give the impression that something is being done (e.g., distributing a pamphlet). To truly address child safety it will be necessary to select evidence-based good practice strategies that may cost more and/or take longer to achieve but in the end will achieve greater results. In an environment of scarce resources and limited time-frames for funding this will likely require collaboration between organizations and working smarter with government and industry to ensure they take up what works. In summary, to implement good practice today the injury prevention community needs to take into account both the specific aspects of children as a target group and the seven broad approaches to child injury prevention and safety promotion that offer proven or promising strategies. It needs to keep in mind that these seven approaches are most effective when they work in combination, and to invest scarce resources into what is known to work. This will also require an understanding of the importance of using good practice and the reasons why it is not implemented more often. The next section provides more detail on the strategies based on the seven broad approaches that are considered current best investments. This guide is intended for all of you. 7

10 SECTION 2 Good practice at-a-glance Injuries are predictable and preventable. Research has shown that there are practices that reduce injury death and disability, most often through a comprehensive approach of education, engineering and enforcement measures. Action needs to be taken to adopt and implement what has been proven to work - the evidence-based good practices while recognizing the interaction between individuals, communities, policies and the physical environment. Evidence regarding cost-effectiveness also exists for a number of these proven good practice strategies thus they provide a significant opportunity to save lives and money. For example; $1 spent on smoke alarms saves $15; $1 spent on bicycle helmets saves $30; $1 spent on child safety seats saves $31; $1 spent on road safety improvements saves $102; and $1 spent on prevention education by paediatricians saves $10.(23) Potential good practice strategies for inclusion in the following ata-glance tables were identified through a review of existing systematic reviews, journal articles and policy documents, and in consultation with child injury prevention and safety promotion experts. Strategies focused on children between 0-14 years of age were then examined against the definition of good practice and resulting criteria developed for the purposes of this project. Evidence statements for strategies that met the criteria were developed and incorporated into the issue-specific good practice at-a-glance tables. Transfer and implementation points were obtained from the same sources in addition to general textbooks dealing with injury prevention and safety promotion. The methodology for selection and write up of case studies is provided in Section 4. Additional information on the most current injury prevention legislation in Canada can be found at 8

11 Good practice for child passenger safety EVIDENCE STATEMENT TRANSFER AND IMPLEMENTATION POINTS ENGINEERING Child passenger restraints lead to decreases in death and injury.(24-27) Rear seating position is the safest place location for child passengers regardless of whether or not there is a passengerside air bag present.(31, 38-40) > When used properly child passenger restraints have been shown to reduce injury by 90-95% for rear-facing systems and 60% with forward facing systems.(28) Research from the USA estimates that when children are correctly installed in appropriate car seas the risk of death or serious injury is reduced by approximately 70%.(27) > Keeping children rear-facing longer has been shown to increase protection by 3-5 times.(29, 30) > Research has demonstrated that in children four to seven years of age, booster seats are estimated to reduce the risk of sustaining a clinically significant injury during a crash by 59%.(31-35) > Parental knowledge and availability, accessibility, cost and ease of use of child passenger restraints will impact their uptake.(36, 37) > Children in the rear row(s) of the vehicle are one half to two thirds times less likely to sustain injury than those in the front.(40) > Uptake of rear seating position for children can be increased through community-based educational campaigns.(41, 42) > Research suggests efforts to encourage rear seating position for child passengers should address parents experiences of pressure to relax seating rules and risk perception as well as provide strategies that support sound parental safety decisions.(43, 44) ENFORCEMENT Legislation of safe child passenger restraints leads to increases in observed use.(37, 45) Case example: Child Passenger Safety Promotion in Aboriginal Communities, Manitoba, Page 36. > Level of enforcement will impact effectiveness by increasing usage.(46) > Legislation is most effective when supported by educational activities.(46) ENFORCEMENT ENGINEERING EDUCATION Community-based intervention combining information dissemination on child passenger restraint safety with enhanced enforcement campaigns leads to increased use. (36, 37, 45) Community-based intervention combining child passenger restraint distribution, loaner programs or incentives with education programs leads to increased use.(36, 37, 45) Case example: Child Passenger Safety Promotion in Aboriginal Communities, Manitoba, Page 36. Seat belts lead to decreases in death and injury. (24, 47-52) Legislation requiring seat belt use in older children leads to increased use.(36, 45, 53) > Important elements of community-based approaches are long-term strategy, effective focused leadership, multi-agency collaboration, involvement of the local community, appropriate targeting and time to develop a range of local networks and programs.(20) > Enforcement campaigns supported by school-based promotional activities have shown large increases in observed seat belt use.(36) > Important elements of community-based approaches are long-term strategy, effective focused leadership, multi-agency collaboration, involvement of the local community, appropriate targeting and time to develop a range of local networks and programs.(20) > More intensive programs involving multiple elements and communication mechanisms are associated with more positive results.(20) > A reliable, well-informed organization is required to run a loaner program given the technical and maintenance checks on car seats.(36) > When used properly seat belts can reduce deaths by 40-50% and serious injury by 45-55%.(51) > Parental knowledge and seat belt availability and ease of use will impact their uptake.(36) > Level of enforcement will impact effectiveness.(54) > Legislation is most effective when supported by educational activities.(46) 9

12 SECTION 2 Good practice for child pedestrian safety EVIDENCE STATEMENT TRANSFER AND IMPLEMENTATION POINTS ENGINEERING Area-wide engineering solutions to reduce pedestrian risk (including pedestrian facilities and/or traffic calming infrastructure) lead to reduction in injuries and are cost effective.(18, 45) Vehicular modifications appear to reduce the risk of pedestrian fatalities.(18, 28) > Traffic calming has shown accident savings of 60% in 30 km/hour (18.6 mph) zones.(55) > Area-wide urban traffic calming schemes reduced the number of injury accidents by 15% (25% on residential streets and 10 % on main roads).(55) > Engineering modifications can be more effective when supported by educational and enforcement activities.(46) > Modifications to car front design that take children into account result in a reduced number of child pedestrian fatalities.(28) > It is estimated that up to 2,100 deaths and 18,000 serious pedestrian and cyclist casualties of all ages could be prevented annually in the European Union with these modifications.(28) ENFORCEMENT Legislation/policy reducing vehicle speeds in residential areas leads to reduced injuries and changes in driver behaviour.(45) Enforcement of legislation/policy reducing vehicle speeds in residential areas leads to reduction in injuries and changes in driver behaviour.(57-59) > In the United Kingdom, introduction of 20 mph (32 km/hour) speed limit zones resulted in 70% reduction in fatal child pedestrian accidents.(56) > Level of enforcement will impact effectiveness.(54, 57, 58) > Legislation is most effective when supported by educational activities.(46) > Level of enforcement will impact effectiveness.(54, 57, 58) > Legislation is most effective when supported by educational activities.(46) ENFORCEMENT EDUCATION Community-based education/advocacy programs to prevent pedestrian injuries in children 0-14 years result in a reduction in injuries.(60) Case example: Pace Car Program, Nova Scotia, Page 38. Pedestrian skills training leads to improved child pedestrian crossing skills.(18) The countries with the best road safety record have national implementation plans which comprise a wide range of measures: low speed limits, speed reduction measures, promotion of secondary safety and publicity aimed at both children and their parents, and drivers.(55, 61) > Effective programs have shown reductions ranging from 12%-54%.(60) > Programs offering a comprehensive package that includes educational, social and environmental strategies are more likely to be successful.(60) > Greater amounts of resources and community commitment afforded to programs allow more complex and comprehensive strategies to be used, which in turn lead to greater success.(60) > Multi-faceted programs and those that involve parents are more likely to be successful.(18) > Practical roadside experience is an essential ingredient of pedestrian skills training.(18) > Building on past policies or international agreements can lead to progress.(55) > Political commitment at the highest level is necessary to make road safety a priority for all in government and society.(55) > Media coverage is an important aspect of national safety campaigns.(54, 55) > A combination of engineering, enforcement and education is most effective.(54) 10

13 Good practice for child cyclist safety EVIDENCE STATEMENT TRANSFER AND IMPLEMENTATION POINTS ENGINEERING Use of bicycle helmets leads to reduction in injuries.(45, 62, 63) Area-wide engineering solutions and traffic calming measures (e.g., speed reduction zones) lead to reduction in child cyclist injuries and are cost effective.(45) Area-wide engineering solutions to reduce cyclist risk (including cycling lanes and pathways) may lead to injury reductions.(18) > Correctly fitted bicycle helmets reduce the risk of head and brain injury by as much as 85%.(45, 62, 63) > Parental knowledge and helmet availability, accessibility, cost and ease of use will impact both helmet use and proper use.(64) > Reducing costs of helmet through give-away programs and discounts facilitates uptake and use.(65) > Engineering modifications can be more effective when supported by educational and enforcement activities.(46) > Engineering modifications can be more effective when supported by educational and enforcement activities.(46) ENFORCEMENT EDUCATION Legislation of bicycle helmets leads to increased use.(18, 64) Case example: Operation Headway, Nova Scotia and Prince Edward Island, Page 40. Community-based education/advocacy programs around child helmet wearing lead to increased helmet wearing.(18, 20, 65, 68) Case example: Operation Headway, Nova Scotia and Prince Edward Island, Page 40. Cycling skills training has shown promise in increasing knowledge and improving observed riding skills in the children who received training.(18) At this time there is no study directly linking skills training and reduction in injury. > Evaluation of mandatory bicycle helmet laws in Canada show a 45% reduction in the rates of bicycle-related head injury in provinces with legislation and in New Zealand there was a 19% reduction in head injuries among cyclists during the first three years of legislation.(55) > In several countries where legislation has been enacted it has not been done until high levels of helmet-wearing have been attained in the population.(65) > Legislation takes time to produce the desired effect following implementation (64) and legislation is most effective when supported by educational activities.(46) > The effect of legislation appears smaller in areas with a higher baseline proportion of helmet use and areas with high socioeconomic status.(64) > The effect of legislation is smaller when helmet law is not inclusive of all ages.(66) > Level of enforcement will impact effectiveness.(54) > Implementers of helmet legislation may wish to address concerns regarding decreased ridership following introduction of legislation as those not in favour of legislation have stated this as an argument against this strategy.(67) However, research from Canada suggests helmet legislation is not associated with a reduction in cycling.(66) > Important elements of community-based approaches are long-term strategy, effective focused leadership, multi-agency collaboration, involvement of the local community, appropriate targeting and time to develop a range of local networks and programs.(20) > Programs are more likely to be effective when they include provision of free helmets, are broad in scope as it relates to target audience and setting, involve parental participation and helmet wearing by riding partners (adults or other children).(65) > Younger children and girls show the greatest effect from campaigns.(45) > Successful interventions have included targeted and mass media education or children and parents, promotion and mandating of helmet-wearing, seizure of bicycles of cyclists not wearing helmets and discounting the price of helmets, however it is not possible to isolate the effectiveness of each intervention.(68) > For children to ride safely in traffic requires that they are knowledgeable about traffic rules, can read and interpret signs, and have the necessary cognitive and motor skills.(69) > The most comprehensive programs have all incorporated helmet education, traffic rules, safety guidelines, and on-bike training into their curricula.(18) > Interventions that repeat the message in different forms and contexts are also more likely to succeed. Therefore, community based education programs that allow for repetition of bicycle safety messages, several opportunities for practice, and parental involvement, may represent a more effective approach to improving bicycle safety in children.(70) > It is possible that young children (under 10 years) may not be able to master the basic cognitive and motor skills necessary for the complex task of riding a bicycle on the road.(70) 11

14 SECTION 2 Good practice for child water safety EVIDENCE STATEMENT TRANSFER AND IMPLEMENTATION POINTS ENGINEERING Expert opinion states that the use of a personal floatation device (PFD) for boating and other water recreational activities is a recommended preventive strategy in the prevention of drowning.(71) Case example: Personal Floatation Device Program, Manitoba, Page 42. Expert opinion states that signs regarding safe behaviours displayed in clear and simple signage are an important preventive strategy in the prevention of drowning.(73) > It is estimated that 85% of annual boating-related drowning incidents could be prevented if the victim had been wearing a PFD.(72) > Level of enforcement will impact effectiveness.(54) > Legislation is most effective when supported by educational activities.(46) > Signage is most effective when supported by educational activities.(73) > International standardization of symbols used on signs should help reduce tourist drowning incidents.(73) ENFORCEMENT Legislation requiring isolation fencing with secure, selflatching gates for all pools (public, semi-public and private, including both newly constructed and existing pools) leads to a reduction in drowning when enforcement provisions are included.(18, 74) Case example: Pool Fencing Bylaw, Ontario, Page 44. > Private pools that are fenced provide 95% more protection against a drowning event.(18) > Level of enforcement will impact effectiveness.(54, 75) > Legislation is most effective when supported by educational activities.(46) > It is highly recommended that parents be strongly encouraged to continue close supervision of their children around pools; no protection system can replace parent supervision.(76) Safety standards for swimming pools may lead to a reduction in drowning.(73) Lifeguards, when adequately staffed, qualified, trained and equipped, seem to be an effective strategy to prevent drowning.(71) > Level of enforcement will impact effectiveness.(54) > Safety standards will be more effective when supported by educational activities.(46) > The presence of lifeguards may deter behaviours that could put swimmers at risk for drowning, such as horseplay or venturing into rough or deep water.(71) > Lifeguards should have appropriate training and hold a suitable current qualification. Re-qualification should be undertaken at regular intervals, and practical rescue and resuscitation skills should be practiced frequently.(71) It has been noted that initial introduction of lifeguard certification may impact availability of qualified lifeguards.(77) > Lifeguard observation points must have a clear and unobstructed view of the area of supervision including both the water and surrounding area.(71) > Lifeguards on duty should be easily identifiable at a distance and in a manner that sets them apart from others at the beach or water recreational facility.(71) > Lifeguard organizations should develop written standard operating procedures that include supervision requirements.(71) 12

15 Good practice for child water safety, continued EVIDENCE STATEMENT TRANSFER AND IMPLEMENTATION POINTS EDUCATION Community-based education/advocacy around PFD use leads to increased use.(18) Water safety skills training (including swimming lessons) improve swimming performance.(18) Case example: Swim to Survive, Ontario, Page 46. > It is estimated that 85% of annual boating-related drownings could be prevented if the victim had been wearing a PFD.(72) > Important elements of community-based approaches are long-term strategy, effective focused leadership, multi-agency collaboration, involvement of the local community, appropriate targeting and time to develop a range of local networks and programs.(20) > Swimming skills are just one potential prevention strategy that must be considered in the context of a multifaceted approach that includes effective barriers, appropriate adult supervision, and training in CPR.(78) In particular it is highly recommended that parents be strongly encouraged to continue close supervision of their children around water; ability to swim does not replace the need for close parent supervision.(76, 79) > Children are highly sensitive to training, are able to retain most skills if lessons are continued, and can use acquired skills in mastering more advanced swimming skills (e.g., diving).(18, 80) > The earliest age at which swimming lessons show improvement in swimming ability is 24 months, but their learning period is much longer than that of older children.(18, 21) > In the past it has been held that children are generally not developmentally ready for formal swimming lessons until after their fourth birthday.(21, 81) While recent evidence is insufficient to support a recommendation that all one to four year-old children receive swimming lessons, there is adequate evidence demonstrating that swimming lessons do not increase the risk of drowning in this age group.(78) > Aquatic programs for infants and toddlers should not be promoted as a way to decrease the risk of drowning.(21, 81) 13

16 SECTION 2 Good practice for falls prevention in children EVIDENCE STATEMENT TRANSFER AND IMPLEMENTATION POINTS ENGINEERING ENFORCEMENT Window safety mechanisms to prevent children from opening windows, such as bars and position locking devices, are an effective strategy to prevent falls.(18, 82) Stair gates have shown to assist in the reduction of falls down stairs to young children when used at the top of stairs in households.(45) Surfacing materials such as sand or wood chips to a depth of cm (9-12 inches) can be recommended as effective injury prevention strategies in preventing playground equipmentrelated injuries. Optimal equipment height to reduce risk of head injury is 1.5 m (5 feet).(18) Case example: Safer Play Equipment on Playgrounds, Ontario, Page 48. Legislation banning baby walkers removes a larger portion of existing risk than parental supervision.(18, 93) Enforcement of standards requiring safe depth of specified types of surfacing materials and regular maintenance of those materials is more effective than standards alone in reducing playground equipment-related injuries.(18, 88) > Window bars have been shown to reduce deaths from window falls by 35%.(18, 82) > Regulations requiring window safety mechanisms on rental housing appears to be most effective approach when working in areas of social deprivation.(18) > Parental knowledge and availability, accessibility, cost and ease of use of window safety mechanisms will impact their uptake.(83, 84) > Parental knowledge and stair gate availability, accessibility, cost and ease of use will impact their uptake.(45, 83, 84) > Pressure gates should not be used at the top of stairs.(85) > Inequalities in rates of uptake and use may be reduced if stair gates are both supplied and installed.(86, 87) However overcoming cost and installation barriers only partially addresses economic disparities, thus further research is required to identify and deal with additional barriers.(86) > Level of enforcement will impact effectiveness.(54, 88) > Regular maintenance of surfacing materials is necessary to retain protective effect.(18, 89) > Standards are most effective when supported by educational activities.(46, 90, 91) > Surfacing depths in the Canadian Playground Standard require cm (6-12 inches).(88, 92) > Level of enforcement will impact effectiveness.(54, 94) > Legislation is most effective when supported by educational activities.(46) > Level of enforcement impacts effectiveness.(54, 88) > Standards are most effective when supported by educational activities.(46, 90, 91) > Surfacing standards address risk of head injury, not injuries to arms and legs.(18, 95) EDUCATION Educational programs encouraging use of fall prevention safety devices such as window safety mechanisms to prevent children from opening windows and down stairs increase use of equipment.(18, 82, 84) > Parental knowledge and availability, accessibility, cost, durability and ease of use of safety measures will impact their uptake.(83, 84, 96) > Provision and instalment of free equipment is more likely to increase use, particularly in lower income settings.(83, 84) > Effective provision of safety equipment involves ongoing support with installation and maintenance.(97) > Timing of education and developing materials and advice (style, language and examples) that suit target communities (e.g., low income, ethnic minority populations) are key to success.(97) > Existence of supporting legislation and adequate enforcement can increase availability of funding for equipment schemes and uptake of safety measures in the home.(97) > Uptake and success of interventions depends on adjusting interventions according to practical limitations and parents cultural expectations. A particular barrier is parents inability to modify rented or shared accommodation.(97) 14

17 Good practice for burn & scald prevention in children EVIDENCE STATEMENT TRANSFER AND IMPLEMENTATION POINTS ENGINEERING Product modification, specifically child resistant cigarette lighters, hearth gates and self-extinguishing cigarettes, are primary prevention strategies where the technologies have been developed, tested and found to be effective and which would prevent many fires from starting if adopted.(18, 19, ) > In the U.S.A., fire deaths associated with cigarette lighters dropped 43% with the adoption of child resistant designs.(18) > Regulations requiring product modifications and their enforcement will increase availability of safe products.(19) > Parental knowledge and modified product availability, accessibility, cost and ease of use will impact their uptake.(83, 84) ENFORCEMENT Legislation regulating the temperature of hot water from household taps is effective in reducing scald injuries.(21) Legislation requiring a safe pre-set temperature (49 o C) for all water heaters has proved a more effective method of reducing scalds than education to encourage parents to turn down water heaters.(18) Legislation requiring installation of smoke detectors in new and existing housing when combined with multi-factorial community campaigns and reduced price coupons is an effective way to increase smoke detector use.(18, 105) Legislation regulating flammability of sleepwear is effective in reducing burn injuries when enforced.(18, 106) Legislation banning the manufacture and sale of fireworks combined with enforcement is the most effective way to restrict the supply.(18, 107) At this time there is no study directly linking restricted supply to injury reduction. > Safe temperatures for hot water from household taps can be achieved by reducing temperature at the water heater or through the use of thermostatic mixing valves (TMVs).(86, 102) > Level of enforcement will impact effectiveness.(54) > Legislation is most effective when supported by educational activities.(21, 46) > Level of enforcement will impact effectiveness.(54, 102) > Legislation is most effective when supported by educational activities.(46, 103) > Cost-effectiveness estimates from Canada suggest that legislation to lower thermostat settings on domestic water heaters along with annual educational notices to utility customers would generate cost savings while reducing the morbidity from tap water scalds in children.(104) > Level of enforcement will impact effectiveness. (54) > Legislation is most effective when supported by educational activities.(46) > Legislation passed in the U.S.A. in 1972 resulted in a 75% reduction in burn unit admissions due to sleepwear related burns.(18, 106) > Level of enforcement will impact effectiveness.(54) > Legislation is most effective when supported by educational activities.(46) > Level of enforcement will impact effectiveness.(54) > Legislation is most effective when supported by educational activities.(46) > Supporting legislation is best targeted at primary and secondary school students and parents.(107) EDUCATION Smoke detector giveaway programs have proven successful when high-risk neighbourhoods are targeted and multi-faceted community campaigns have the specific objective of installation of working smoke detectors.(45) > Important elements of community-based approaches are long-term strategy showing commitment to the issue, effective focused leadership, multi-agency collaboration, involvement of the local community, appropriate targeting and time to develop a range of local networks and programs.(20) > The distribution of smoke alarms alone is insufficient for improving installation rates; programs containing an education component showed more success.(87) > Existence of supporting legislation and adequate enforcement can increase availability of funding for equipment schemes and uptake of safety measures in the home.(97) > Addressing cost and installation only partially addresses economic disparities, more research is required to identify additional barriers.(86) > Timing of education and developing materials and advice (style, language and examples) that suit target communities (e.g., low income, ethnic minority populations) are key to success.(97) > Uptake and success of interventions depends on adjusting interventions according to practical limitations and parents cultural expectations. A particular barrier is parents inability to modify rented or shared accommodation.(97) > Interventions integrated into wider health programs, where trusting relationships with householders are cultivated and/or where specific safety issues identified by a community are responded to show greater success in increasing smoke alarm installation rates.(87) 15

18 SECTION 2 Good practice for burn & scald prevention in children, continued EVIDENCE STATEMENT TRANSFER AND IMPLEMENTATION POINTS EDUCATION Education/advocacy campaigns around fireworks are useful as supplemental efforts and can be used to build support for legislation.(18) Fire safety skills training increases knowledge and behaviour of both children and parents.(18, 108) At this time there is no study directly linking training to injury reduction. > Important elements of community-based approaches are long-term strategy showing commitment to the issue, effective focused leadership, multi-agency collaboration, involvement of the local community, appropriate targeting and time to develop a range of local networks and programs.(20) > Programs using active participation by children in learning fire responses are more effective than those using passive methods.(108) > When evaluating programs, actual demonstration of skills is likely a more reliable marker of children s real response in fire situations than providing correct answers on a written test. (108) > The addition of fear reduction techniques and teaching the rationale supporting the use of correct fire response behaviours may significantly improve skill retention.(108) > Periodic repetition of material is required for maintenance of knowledge and skills.(108) > The use of figures of authority in fire safety skills training (e.g., fire fighters) may increase knowledge gain.(108) 16

19 Good practice for poisoning prevention in children EVIDENCE STATEMENT TRANSFER AND IMPLEMENTATION POINTS ENGINEERING Secure storage for poisons removes a larger portion of poisoning risk than parental supervision and may be an effective means of preventing poisoning injury.(109, 110) > Studies of how children access poisons suggest that the most vulnerable time is when the poisons are in use and that safe packaging alone cannot compensate for unsafe storage or use. This speaks to the need for improved safety of home storage of medications and improved home dispensing practice.(111, 112) > Changes to the fixed environment need to be supported by regulation and education for industry and the community, with clear labelling (and clear administration instructions) on the package, parental education and improved supervision, ongoing paediatric counselling, and increased accessibility and affordability.( ) ENFORCEMENT Legislation of child resistant packaging reduces the incidence of poisonings.(18, 45, 114) > In the USA the use of child resistant packaging was associated with a 34% reduction in the aspirin related child mortality rate.(114) > Level of enforcement will impact effectiveness.(54) > Legislation is most effective when supported by educational activities.(46) EDUCATION Poison control centres result in considerable medical savings if the public is well informed regarding the use of their local poison control centre.(18) > Parental knowledge and availability, accessibility and ease of use of poison control centres will impact their use. Educational activities may assist in increasing parental knowledge.(18) 17

20 SECTION 2 Good practice for choking/strangulation prevention in children EVIDENCE STATEMENT TRANSFER AND IMPLEMENTATION POINTS ENFORCEMENT Product modification through legislation permanently removes a larger portion of existing choking/strangulation risk than parental supervision and is recommended for safe crib/cot design and other entrapment hazards.(18) Product banning/regulation through legislation permanently removes a larger portion of existing choking/strangulation risk than parental supervision.(18, 115) Legislation that requires product warning labels to include an explanation of the specific hazard is more effective than non-specific labels.(18) > Level of enforcement will impact effectiveness.(54) > Legislation is most effective when supported by educational activities.(46) > Product banning/regulation through legislation is recommended for latex balloons, inedible material in food products, pull cords on window coverings (e.g., horizontal blinds) and drawstrings on children s clothing.(18) > Level of enforcement will impact effectiveness.(54) > Legislation is most effective when supported by educational activities.(46) > A label merely stating, For children ages three and up, doesn t adequately explain the risk to the parent.(18) > Level of enforcement will impact effectiveness.(54) > Legislation is most effective when supported by educational activities.(46) 18

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